What is Fraud

What is Fraud?

The intentional misrepresentation of a material fact on a health care claim in order to persuade BCBST to process and pay a false claim.

The act of deceiving or misrepresenting of health care services.

Five Elements of Health Care Fraud

Misrepresentation or concealment of a material fact on a health care claim

Knowledge of the falsity of the misrepresentation

Intent to deprive or harm BCBST and its customers financially

BCBST, a victim, acting on the misrepresentation

Financial damage to BCBST and its customers

Who Commits Fraud?

Providers

Subscribers

Non-Subscribers

Groups

Claims Processors

Employees

Brokers and Agents

Where Can Fraud Occur?

What is the Cost of Health Care Fraud?

The cost of health care fraud is estimated by the American Medical Association, National Health Care Anti-Fraud Association, Certified Fraud Examiners, and Department of Health and Human Services/Offices of Inspectors General to be between 3% and 14%. In 2000, BlueCross BlueShield of Tennessee paid $7.4 billion in health care benefits. This means BCBST could have potentially lost between $ 222,000,000 and $1,036,000,000.

Help Fight Fraud

This process may result in administrative or civil action taken against the person committing the act, in an attempt to recover dollars lost. Any act believed to be of a criminal nature will be referred to the appropriate law enforcement agency for their consideration.